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JOURNAL OF ORAL & MAXILLOFACIAL RESEARCH
Farronato et al.
Postsurgical Orthodontic Treatment Planning: a Case Report
with 20 Years Follow-up
Giampietro Farronato1, Umberto Garagiola1, Vera Carletti1, Paolo Cressoni1, Carmen Mortellaro2
Department of Orthodontics, University of Milan, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan,
Italy.
2
Division of Oral Maxillofacial Surgery, Department of Oral Medicine and Diagnostic Sciences, University of Eastern
Piedmont Novara, Novara, Italy.
1
Corresponding Author:
Giampietro Farronato
Department of Orthodontics
University of Milan
Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico
Via Della Commenda 10, Milan 20122
Italy
Phone: +0039 2 55032520
Fax: +0039 2 50320239
E-mail: [email protected]
ABSTRACT
Background: Traditionally, maxillofacial deformities are corrected surgically after an initial orthodontic treatment phase.
However, in this article, the authors emphasize the postsurgical therapeutic protocol which is extremely important for
determining the final and permanent retention of the corrected occlusion.
Methods: A 55 year old female with severe skeletal Class II malocclusion is presented. Combined surgical and orthodontic
correction of the malocclusion was used.
Results: The step-by-step procedure the authors followed for the postsurgical therapy is described. The goals of the postoperative
therapy were to restore and rehabilitate neuromuscular function, obtain occlusal stabilization, grind teeth selectively, and final
occlusion retention. The importance of a surgical occlusal splint for rehabilitating stomatognathic neuromuscular function
postoperatively was demonstrated. Furthermore, the orthodontic-prosthodontic treatment ensured occlusion stability after the
surgical correction. The long-term results confirmed the efficacy of the treatment protocol presented here from both functional
and aesthetical perspectives.
Conclusions: Postsurgical orthodontic treatment is an important step in the surgical and orthodontic therapy of maxillofacial
deformities.
Keywords: dental occlusion; malocclusion; orthodontics, corrective; occlusal splints; maxillofacial orthognathic surgery;
orthognathic surgical procedures.
Accepted for publication: 14 April 2011
To cite this article:
Farronato G, Garagiola U, Carletti V, Cressoni P, Mortellaro C. Postsurgical Orthodontic Treatment Planning: a Case Report
with 20 Years Follow-up.
J Oral Maxillofac Res 2011 (Apr-Jun);2(2):e4
URL: http://www.ejomr.org/JOMR/archives/2011/2/e4/v2n2e4ht.pdf
doi: 10.5037/jomr.2011.2204
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INTRODUCTION
Surgical-orthodontic treatment is universally recognized
as the best therapeutic option for the adult patient with
maxillofacial disharmony from both dental and skeletal
perspectives [1]. This treatment is organized into four
phases: presurgical orthodontic therapy, orthognathic
surgery, postsurgical orthodontic therapy, and retention
[2,3]. All of these steps are important for the success of
orthognathic surgery, but this article focuses primarily
on the postsurgical phase.
Goals of the postsurgical therapy are surgical fixation,
restoration and rehabilitation of neuromuscular function,
occlusal stabilization, selective grinding of teeth and
final occlusion retention. The postsurgical phase has to
achieve the restoration of a good neuromuscular function
through a progressive reprogramming of the muscular
and dental periodontal proprioception adequate to the
new spatial situation of the maxillary and mandibular
skeletal bases [4].
Final orthodontic and prosthodontic treatment permits
correct occlusion, which will be stabilized by a good
spatial jaw relationship, correct neuromuscular
function, and parafunction prevention. It is evident that
after surgical jaws correction, the adaptive changes in
the orofacial complex contribute to causing relapse
[4]. The occlusion should be as stable and optimal as
possible to eliminate the reasons for relapse.
In this article, the authors underline the importance of
postsurgical orthodontic treatment in the combined
surgical-orthodontic therapy of maxillofacial deformities.
Postsurgical treatment phases
The approach presented here is characterized by the
exact order of the various therapeutic phases, and this
sequence is strictly related to goals of the postsurgical
orthodontic treatment. These goals are postsurgical
retention, restoration and rehabilitation of oral function,
occlusal stabilization, retention, and selective grinding
of teeth [5-8].
Postsurgical retention is carried out with intermaxillary
fixation, and is kept in place for about 21 days
(Figure 1 A). The restoration of function begins after
removing the intermaxillary fixation. An occlusal splint
is fixed to the orthodontic arch with ligature wires and the
patient begins to open and close his or her mouth using the
indentations present in the splint as guides. For the first
few days, the width of the mouth opening is obviously
reduced as a consequence of immobilization and the new
occlusal position with a different skeletal orientation
and the consequent alteration in dental, skeletal, and
muscular proprioceptive receptors. After 2 weeks,
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the patient usually opens his mouth wide enough,
following the muscular reprogramming carried out
under the guidance of the occlusal splint (Figure 1 B).
When oral function is restored sufficiently, the function
is rehabilitated with a modification of the occlusal
splint; lateral disclusive and protrusive excursion guides
are created to perfect the dynamic jaw movements.
During this phase, the occlusal splint can be cut distally
at the canines to avoid any dental interference in the
posterolateral sectors. All the dental elements must have
brackets tied to a fixed appliance to avoid unwanted
extrusion, except when this is specifically required
by the treatment plan. The patient is asked to perform
opening and closing, lateral and protrusive exercises
three times a day (Figures 1 C and 1 D).
After 3 to 4 weeks, good functional rehabilitation is
obtained, permitting the removal of the occlusal splint
and progression to the final occlusal stabilization. This
principally involves postsurgical orthodontic treatment
aimed at completing the occlusion retention obtained
after surgery. Once the occlusal splint is removed, one
must check to see if any gross prematurities or occlusal
interference occur. These must be removed immediately,
because the occlusion and function must be kept stable.
First, the passive archwires must be removed and the
position of the brackets revised as needed to optimize the
subsequent treatment. Because the occlusal conditions
have changed, new strategic position of the brackets
aimed at obtaining the final occlusal relationship often
becomes important. Thus, active archwires are used in
relationship to the necessary dental movements. The
completion of the treatment does not differ from that
of any other traditional orthodontic therapy. In this
phase, the maintenance of good periodontal conditions
becomes particularly important. This contributes to the
stability of the final result. During the final orthodontic
phase, it may be necessary to modify the temporary
restorations prepared preoperatively in view of the
planned final occlusion. It may also be necessary to
prepare another prosthesis to restore compromised
dental elements. The postsurgical orthodontic phase
lasts about 6 months (Figure 1 E). When the orthodontic
appliance is removed, the retention phase, which lasts
4 to 6 months, follows. Preference is given to the use
of a gnathologic positioner as the best instrument to
maintain the achieved results and to improve them if
necessary; this is obtained from the occlusal information
incorporated in the setup of the positioner.
The patient is instructed to use the positioner for 4 h
during the day and all night. After about 6 months, the
daytime use of the positioner is suspended, the device is
lightened and made passive, and the patient is advised
to use it during the night as protection against possible
parafunctions that could nullify the result with time.
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A
E
B
F
C
G
D
H
Farronato et al.
Figure 1. A = postsurgical intermaxillary fixation;
B = mouth opening width on removal of the intermaxillary fixation;
C and D = function rehabilitation with the modification of the occlusal splint;
E = occlusal stabilization;
F, G and H = selective grinding of teeth to finalize the occlusion.
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At the beginning of the retention phase and at periodical
checkups, the patient undergoes selective occlusal
grinding to stabilise the centric position and to remove
any prematurities or interferences with the centric
and eccentric movements (Figures 1 F to 1 H). The
selective grinding of teeth is used to obtain a centered
mandibular position, with bilateral stopping contacts,
with coincidence between centric relation and centric
occlusion. Concerning the mandibular dynamics, the
authors preferably look for disclusive canine guidance
in the lateral movements and incisor guidance in the
protrusive movements, according to the traditional
teachings on occlusion. The authors firmly believe that
any prematurities or dislocating interference or the
development of daytime or nighttime parafunctions
are the most frequent causes of relapse from the result
achieved at the end of active treatment [4,9,10].
CASE DESCRIPTION AND RESULTS
A 55 year old female patient applied to the Department
of Orthodontics, University of Milan, Fondazione
A
B
C
Farronato et al.
IRCCS Cà Granda, Ospedale Maggiore Policlinico,
Milan, Italy, because she noticed that her teeth were
becoming mobile. The patient had been treated in
the past for periodontal problems, but had recently
noticed a serious worsening of her dental health. The
oral cavity examination revealed a serious Class II
malocclusion with a substantial increase in the incisor
overjet (11 mm) and overbite (8 mm). A wire splint
was fixed on the maxillary front teeth; periodontal
pockets and increased dental mobility were clearly
noticeable for most of the teeth in both dental arches.
The patient suffered from a temporomandibular joint
(TMJ) dysfunction syndrome, a symptom complex
consisting of pain, masticatory muscle tenderness,
difficult chewing, clicking in the joint, limitation or
alteration of mandibular movement, and cervical pain
and headache associated to otovestibular symptoms
(Figures 2 A to 2 H).
The lateral cephalometric radiograph showed a skeletal
Class II malocclusion with mandibular retrognathism
according to the classification of Giannì [11] (SNA =
81.8; SNB = 76.1; ANB = 5.7); the anterior skeletal
vertical dimension was reduced by about 5.5 mm
(SOR/SNA = 63.7 mm; SNA/ME = 63.4).
The panoramic radiograph provides wide
coverage of the oral structures, with
relatively low radiation exposure using
moderately inexpensive equipment [12]
and demonstrated the absence of tooth
#47 and a generalized loss of supporting
alveolar bone tissue. The anterior jaw
segments were the most damaged.
Based on these clinical and radiological
examination results, the authors made a
diagnosis of skeletal Class II, skeletal deep
bite, retrognathic mandibular form; dental
Class II, dental deep bite; and periodontal
problems of an inflammatory and traumatic
nature. Surgical-orthodontic treatment
was planned. The patient first underwent
D
Figure 2. A, B, C and D = pretreatment facial and intraoral photographs.
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initial periodontal preparation lasting 6
months, and then fixed appliances were
bonded to the dental arches to make them
suitable for the planned operation, which
consisted of mandibular advancement and
clockwise mandibular rotation to correct
the skeletal Class II and skeletal deep bite.
During presurgical phase (14 months),
dental interferences were eliminated and the
real discrepancy between skeletal jaw and
mandible was restored.
The most important aims of the orthodontic
treatment before surgery were dental
alignment to eliminate ill-positioning and
E
Farronato et al.
G
F
H
Figure 2. E, F, G and H = pretreatment posteroanterior, panoramic radiographs; lateral cephalometric radiograph and tracing before
treatment.
A
dental crowding, dental-alveolar decompensation to
eliminate dental compensation by forward inclination
of the anterior-inferior teeth and backward inclination
of anterior maxillary teeth, pointing out the real extent
of the sagittal skeletal defect, and the alignment of the
dental arches, in their final position, matching them
together perfectly.
The surgery, performed in 1990, consisted of a bilateral
mandibular advancement of 10 mm and rigid fixing
plates by a bilateral sagittal Obwegeser-Dal Pont
osteotomy. The diagnosis determined where to operate
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B
C
Figure 3. A, B and C = retention phase.
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and gave information on the vectorial directions of the
surgical movements of the bones to correct the skeletal
vertical dimension. The sagittal shifts corrected the
skeletal Class II. The clockwise rotation of the mandible
realized the correction of the skeletal deep bite.
Postoperatively, the jaws were fixed for 4 weeks using
intermaxillary fixation.
After postsurgical retention using intermaxillary
fixation, the restoration phase began and oral function
was subsequently rehabilitated with an occlusal
splint using our protocol (Figures 1 A to 1 H). The
postoperative orthodontic treatment lasted 6 months,
and optimized the dental intercuspidation, using
intermaxillary elastics.
Occlusal stabilization followed to complete the
postsurgical orthodontic phase. Before removing the
archwires, two Maryland-type periodontal splints were
applied to the anterior segments of both arches. A
positioner was used to maintain the results of surgicalorthodontic treatment. The patient subsequently
underwent selective grinding to finalize the occlusion
and maintain stability (Figures 3 A to 3 C).
The posttreatment cephalometric radiograph showed
skeletal Class I (ANB = 3.3) according to Giannì [11]
A
B
C
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with restoration of the correct anterior skeletal vertical
dimension. The panoramic radiograph showed
maintenance or improvement of the periodontal
condition present at the beginning of treatment
(Figures 4 A to 4 H).
All of the craniomandibular disorders were reduced
significantly, especially the muscular spasms and
headache. The final electromyographic examination
showed qualitative and quantitative improvement in the
temporal and masseter muscles.
Long-term clinical follow-up (20 years) has confirmed
the results (Figures 5 A to 5 D).
DISCUSSION
For the surgical treatment of mandible deformities, the
authors prefer non-rigid fixation techniques. The authors
are aware that rigid fixation has some indisputable
advantages, especially greater comfort for the patient in
the postsurgical phase; it also has negative aspects that
do not favour its indiscriminate use [13]. We believe
that the greatest limitation of rigid fixation is the need
for an absolutely precise surgical technique, particularly
when positioning the proximal segment of
the osteotomized mandible. Rigid fixation
also increases the risk of condylar rotation
with distraction when the proximal segment
is fixed to the distal segment rigidly [14-16].
We attribute many of the relapses seen
in orthognathic surgery to the fact that
repositioning of the skeletal bases takes place
in a spatial situation that is not compatible
with the limits of the patient’s neuromuscular
tolerance, and not to incorrect procedures
or inaccurate techniques. If the position of
the jaws is not in harmony with the function
of the neuromuscular system, it does not
work to stabilise the surgical result, but
has a negative effect, creating a basis for
D
Figure 4. A, B, C and D = posttreatment facial and intraoral photographs.
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relapse [17-19].
The incidence of TMJ pain and dysfunction
in adults appears to differ among studies.
Malocclusion is one of the suggested etiological
factors in internal derangements of the TMJ
[20], whereas maxillomandibular relationship
disharmony formed the basis of most of the early
theories of the etiology of “TMJ syndrome”
[21]. The correction of discrepancies in
occlusion and maxillomandibular relationship
by orthognathic surgery should improve TMJ
function [22,23]. Although some authors [24,25]
advocate orthognathic surgery in cases with TMJ
Farronato et al.
E
G
F
H
Figure 4. E, F, G and H = posttreatment posteroanterior, panoramic radiographs; lateral cephalometric radiograph and tracing after
treatment.
symptoms in combination with dysgnathia, it is still
unclear whether there is any association between these
two phenomena [21,26]. Conversely, orthognathic surgery
can produce TMJ symptoms by changing the position
of the mandible and maxilla relative to each other and
consequently the position of the condyle in the glenoid fossa
[27,28]. Mandibular ramus osteotomies will influence this
position directly [29], whereas the influence in maxillary
C
A
B
D
Figure 5. A, B, C and D = posttreatment facial and intraoral photographs after twenty years.
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osteotomies will be indirect, because of autorotation
[30,31].
Because compliance of the neuromuscular system is
difficult to predict in each patient, the use of a method
that requires a predetermined final skeletal position
without the possibility for successive adjustments
represents a risk that must be examined carefully. The
authors prefer to use surgical techniques that do not result
in the complete detachment of the mandibular muscles,
and prefer to fix the mandibular segments using wire
osteosynthesis or mini-plates for their uniting action
only, without the use of transcortical screws or other
extremely rigid systems. Postoperatively, the muscles
serve to keep the proximal segment of the mandible in
the correct condylar relationship and callus formation
may be influenced by the neuromuscular response of the
patient as soon as the stomatognathic function returns to
normal [32].
The goal of presurgical orthodontics is to position the
teeth, allowing an optimal surgical correction of the
jawbones. While intra-arch alignment is similar to
conventional orthodontics, leveling is not carried out
automatically in surgical patients. In open-bite cases,
steps within the arches are an indication for segmental
surgery. Orthodontic leveling will be limited to the
segments, and segments will be leveled with differential
intrusion at surgery. In deep-bite/short-face patients,
as in this case report, leveling a severe curve of Spee
should be done after surgery. Anteroposteriorly, dental
compensations are removed by ideally positioning the
teeth relative to their skeletal bases. This will make the
malocclusion look worse presurgically, but it will show
the true entity of the skeletal problem, thus facilitating
an optimal surgery [33]. It is important to recognize
if a transverse problem is skeletal or dental and if the
treatment should be done orthodontically, by segmental
surgery, or by surgically assisted palatal expansion.
Postsurgical orthodontics will bring teeth into correct
Farronato et al.
position and proper intercuspation within a reasonable
time period [32,33].
CONCLUSIONS
In surgical-orthodontic treatment, the correct control
of the postsurgical orthodontic phase is as important as
the presurgical orthodontic phase. A good final result
depends not only on the initial diagnosis, but also on the
exact planning and execution of the orthognathic surgery.
Postoperative orthodontic therapy is used to finalize and
perfect the dental occlusion relative to the new skeletal
relationships. In the postsurgical phase, it is important
to restore neuromuscular function through progressive
reprogramming of muscular and dental-periodontal
proprioception that is adequate for the new spatial
situation of the maxillary and mandibular skeletal bases.
Finally, the orthodontic and prosthodontic treatment
permits correct occlusion, which will be stabilized by
a good spatial jaw relationship, correct neuromuscular
function, and the prevention of parafunction. Aesthetics,
function, stability, and treatment time have to be
considered for the decision-making process.
The therapeutic treatment of these serious anomalies
must be neither orthodontic nor surgical alone.
Orthognathic surgery is important when it is considered
as part of the therapeutic method. A different treatment
approach leads to poorer functionality, and the problem
of a relapse.
ACKNOWLEDGMENT
STATEMENTS
AND
DISCLOSURE
The authors report no conflicts of interest related to this
study. No external funding, apart from the support of
the authors’ institution, was available for this study.
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To cite this article:
Farronato G, Garagiola U, Carletti V, Cressoni P, Mortellaro C. Postsurgical Orthodontic Treatment Planning: a Case Report
with 20 Years Follow-up.
J Oral Maxillofac Res 2011;2(2):e4
URL: http://www.ejomr.org/JOMR/archives/2011/2/e4/v2n2e4ht.pdf
doi: 10.5037/jomr.2011.2204
Copyright © Farronato G, Garagiola U, Carletti V, Cressoni P, Mortellaro C. Accepted for publication in the JOURNAL OF
ORAL & MAXILLOFACIAL RESEARCH (http://www.ejomr.org/), 14 April 2011.
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